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Y6 Senior Surgery > Vascular > Flashcards

Vascular Flashcards

1
Q

what is aortic dissection

A

tear in the tunica intima of the aorta

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2
Q

RF for aortic dissection

A

HTN, recent heart surgery, bicuspid aortic valve, Connective tissue disorders (marfan’s, ED), pregnancy, syphilis, cocaine use

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3
Q

How do you classify Aortic Dissection

A

Stanford Type A: ascending aorta (2/3 of cases)
Stanford type B: descending aorta (1/3)

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4
Q

How do you manage stanford TA

A

aortic root replacement surgey

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5
Q

how do you manage stanford TB

A

Bed rest and beta blockers

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6
Q

classical sx of aortic dissection

A

Tearing central chest pain
radiates to back

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7
Q

What is BP like in aortic diss

A

May be high or low
>20mg difference BP between arms

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8
Q

what murmur could you hear with aortic diss

A

AR

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9
Q

How do you investigate definitively Aortic diss

A

Stable: CT Angio
Unstable (cannot be taken to CT): TOE/TTE

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10
Q

What preliminary ix are necessary if suspecting aortic diss

A

ECG (ischaemia)
CXR (widened mediastinum)
FBC (haemoglobin)
X match, group and save

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11
Q

What are the three presentations of Peripheral Arterial Disease

A
  1. Intermittent claudication (Chronic Limb Ischaemia)
  2. Critical Limb Ischaemia
  3. Acute life-threatening Ischaemia
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12
Q

What is intermittent claudication

A

Decreased arterial supply to the limbs usually due to atherosclerosis

leading to increased oxygen demand upon exercise that cannot be met by the local vasculature

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13
Q

What are RF of intermittent claudication / PAD

A

MODIFIABLE:
smoking
dyslipidaemia
hyperglycaemia
HTN

NON-MOD:

  • male gender
  • increased age
  • PMH / FH
  • genetic RF
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14
Q

How does chronic limb ischaemia progress(fontaine classification)

A
  1. asymptomatic
  2. intermittent claudication
  3. ischaemic pain at rest
  4. ulceration / gangren
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15
Q

how does intermittent claudication present

A

CRAMPING pain in calves or buttocks after walking a determined distance
resolves with rest
this is reproducible
no pain if at rest

due to increased oxygen demand that cannot be met during exercise by the local vasculature

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16
Q

If intermittent claudication causes pain in the calves / buttock, which arteries are affected?

A

calves = SFA

buttock: = common / internal iliac

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17
Q

What are clincal findings for intermittend claudication?

A

PULSE pattern will tell you where blocklage is

No ulcers

Buerger’s negative

ABPI >0.5

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18
Q

How do you investigate intermittent claudication?

A

Exercise treadmill ABPI

Duplex

Angiography (CT / MR / digital subtraction)

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19
Q

how do you manage intermittent claudication

A
  1. Conservative: LIFESTYLE CHANGES
    - stop smoking
    - improve diet
    - improve exercise, try to walk through the pain (as this will increase collateral circulation)
  2. Medical: RF control
    - stop smoking
    - treat HTN
    - antiplatelet (clopi)
    - statin
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20
Q

What is leriche’s syndrome

A

peripheral artery disease affecting the AORTIC BIFURCATIOJn

opresents as buttock / thigh pain + erectile dysfunction
with weak or absent femoral pulses

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21
Q

What is critical limb ischaemia

A

significant arterial stenoosis causing severe impairment of blood flow to limbs, presenting with at least one of the following:

  • ABPI <0.5 or ankle artery pressure >40
  • Ischaemic pain >2 weeks
  • Rest pain or tissue loss (ischaemic lesion / gangrene / ulceration)

ARTERIES are not able to meet BASELINE DEMAND

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22
Q

How do you manage critical limb ischaemia

A

Same as intemrittent claudication (modify RF)

  • Endovascular repair (angioplasty or stenting)
  • surgical tecnique (bypass or embolectomy)
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23
Q

What is acute limb ischaemiA

A

SUDDEN drop in blood supply to the limb
it threatens limb viability (if not managed within 6 hours, limb will be lost)

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24
Q

what causes acute limb ischaemia?

A

ACUTE CAUSE - either thrombosis or embolus

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25
Q

what are the 6 Ps of acute limb ischaemia

A

Pain
pallor
perishingly cold
pulseless

paralysis
parasthesia

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26
Q

what is the management of acute limb ischemia

A

NBM, IV hydration, analgesia
Unfractionated heparin to prevent clot extension
If embolic cause: embolectomy
If thrombotic cause: angioplasty with stent, thrombolysis, bypass, ampitation

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27
Q

when is thrombolysis viable in acute limb ischaemia?

A

With ACUTE ON CHRONIC limb ischaemia (i.e. the limb still has some viable collaterals. so it is not as severe)

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28
Q

what is Buerger’s disease

A

recurrent inflammation and thrombosis of arteries and veins in lower limbs, with uncertain aetiology

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29
Q

what is the biggest RF for buerger’s disease

A

SMOKING q

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30
Q

what is Buerger’s disease presentation

A

Raynauds of LL
intermittent claudication
pain at restn
sensitivity to cold
absent peripheral pulses

31
Q

what are key investgations for PAD

A

Cardiovascular risk assessment (blood glucose, cholesterol, BP, ECG)

  1. ABPI
  2. Duplex USS
  3. CT / MR angiograpy

Consider Intra arterial Digital subtraction angiography (gold standard view of anatomy and therapeutic potential with angioplasty)

32
Q

What are ABPI ranges

A

Normal: 0.9-1.2

0.8-0.9 = mild
0.5-0.8 = moderate
<0.5 = severe

>1.2 = indication of abnormal calcification (stiff arteries)

33
Q

What ABPI should you refer to vascular surgeons

A

<0.8 or >1.3

34
Q

what is amangement of PAD

A

asymptomatic / intermittent claudication: risk factor modification

  • conservative: quit smoking, WL, exercise, foot care
  • medical: atorvastatin 80mg + clopi 75mg

sym,ptomatic:

  • angioplasty, stenting, bypass
  • lst resort: amputation
35
Q

what is deep venous insufficiency

A

inability of veins to drain blood adequately due to DVT / valvular insuff + varicose feins

36
Q

RF deep vain insuff

A

advanced age, female, pregnancy, prior DVT / phlebitis, smoking, obesity

37
Q

signs of chronic venous insuff

A

lipodermatosclerosis
haemosiderin deposition
venous ulcers
vemnous eczema

38
Q

hhow do you manage chronic venous insuff

A

compression bandages
surgical graft

39
Q

how do you diagnose a DVT

A

Well’s score
>=2 : DVT likely, so perform USS leg <4 hours > if positive, DOAC 3m (provoked) or 6m (unprovoked)
if USS negative, check D dimer. if D dimer positive, repeat USS in 1 week

<2: DVT unlikely, check D dimer within 4 hours. If D dimer +ve, do USS

40
Q

what further investigation must you do for unprovokedc DVT

A

CT Abdo to identify possible malignancy

41
Q

what is the difference in loaction between venous and arterial ulcer

A

venous in GAITER region (between middle calf and medial malleolus)

arterial in pressure points on foot/toes

42
Q

what is the difference in aspect between venous and arterial ulcer

A

venous = shallow, flat margins. slough at base with granular tissue

arterial = punched out, deep irregular shape, minimal exhudate

43
Q

what are coexisting signs with venous disease

A

haemosiderin deposition
lipodermatosclerosis (champagne bottle)
venous ulcers

varicose eczema (dry, flaking)
pitting oedema
thrombophlebitis

bleeding

44
Q

what are coexisting signs with arterial ulceration

A

thin shiny skin
hairless
pallor on leg elevation
absent/weak pulses

45
Q

what is an AAA

A

dilatation of aorta to >50% normal diameter / >3cm

46
Q

RF AAAA

A

HTN
smoking
hypercholesteraemia
Males (higher AAA risk), females (higheer rupture risk)

47
Q

what kind of screening is offered for AAA

A

to men 65+
single abdominal USS

48
Q

what outcomes of AAA screening dictate management

A

>5.5 >> 2 week vasc referral
4.5 to 5.5 >> fu scan 3 months
3 to 4.5 >> fu scan 12 months

49
Q

How do you manage AAA

A

Emergency: open or endovascular repair (depending on center)

Non-ruptured:

  • conservative mx (with followup) if aneurysm <5.5cm diameter
  • elective repair once risk of rupture becomes grearer than risk of surgery
50
Q

what are tx for varicose veins

A
  • endothermal ablation
  • foam sclerotherapy
  • surgical stripping (rarely don)
51
Q

what is the typical pain in critical limb ischaemia

A

critical limb ischaemia: pain at rest
often in sleep
relieved by DEPENDNCY (hanging foot off side of bed)

52
Q

what are the two types of gangrene

A

wet (infected)
dry ( noo infection)

53
Q

what is the pathophys difference between critical limb ischaemia and acute limb ischaemia

A

ALI is SUDDEN drop in arterial perfusion
Due to thombosis (stenosed vessel with plaque rupture) or embolus (AF/valve disease)

54
Q

What are common sites of aneurysmal disease

A

Abdominal aorta (infrarenal)

Popliteal artery

55
Q

Complications of aneurysmal disease

A

rupture

embolus

thrombodsis

DVT

fistula (if syphilic)

56
Q

S/S varicose veins

A

dragging, aching pain

swelling

itching

restless leg

night cramps

57
Q

RF varicose veeins

A

pregnancy

lots of standin g

obesity

DVT valve distruction, AV malformation

58
Q

what tests can you do on varicose veins

A

Cough impulse

Tap test (chevrier’s test - tap proximally and feel for impulse distally)=

Tourniquet test (apply tourniquet to compress SFJ > stand patient > id distal veins do not fill, this means this area is controlled and the incompetent valve is ABOVE tourniquet)

59
Q

How do you do Buerges test

A

Lift both legs up slowly

One leg will blanche - due to reduced arterial perfusion (note what degree angle this is - the smaller the angle, the more severe the PAD)

Then swing legs across the bedside - the blanched foot will become hyperaemix (so brick red)

60
Q

what does a midline laparotomy expose in vascular surgery?

A

the abdominal aorta

61
Q

what does a groin scar indicate?

A

femoral access scar

62
Q

midline laparotomy + (bilat) groin scar = which surgery?

A

(bilateral) aortofemoral bypass

63
Q

groin scar + medial leg scar =

A

femoral popliteal bypass

64
Q

what does the medial leg scar give access tpo

A

long saphenouus vein harvest

65
Q

arterial anatomy to LL

A

Aorta bifurcates into R and L common iliac

COMMON ILIAC bifurcates into internal and external iliac

EXTERNAL ILIAC > common femoral > profunda femorios & supperficial femoral

superficial femoral travels through ADDUCTOR CANAL to become the policteal arteri

POPLITEAL ARTERY branches off fiirst the anterior tibial, then splits into posterior tibial (medial) and fibular (lateral)

Anterior tibial becomes dorsalis pedis

66
Q

which drug can be prescribed as finial line in intermiittent claudication

A

naftidrofuryl oxalate (potent vasodulator)

67
Q

which two drugs must ALL patents with PAD be on

A

Statin (atorvastatin) + anti-platelet (clopidogrel)

68
Q

what other condition other than size do you need to refer abdominal aortic aneurysm to vascular surgeons for

A

if RAAPIDLY ENLARGING

so >1cm growth per annum in size

69
Q

how do you differentite thrombys / embolus in ALI?

A

Thrombus: patient will have pre-existng claudication, absent or reduced pulses in the other limbs, widespread vascular disease

Embolus: no prior claudication, sudden onset painiful leg, obvious source of embolus (AF, MI)

70
Q

which systemic condition is linked to vessel calcification> abnormal ABPI readings

A

T2DM

71
Q

what does the presence of abdominal pain in the context of AAA indicate?

A

that there is HIGH LIKELYHOOD OF RUPTURE

72
Q

what is the difference in timeline of sx between when you should use ABPI and handheld doppler

A

ABPI if suspecting chronic/critical limb ischaemia

Doppler if suspectinig acute limb threatening ischamia!

73
Q

indications for referring pts with venous disease to vasc ssurgeoons

A
  • varicose veins sx (‘heavy’ or ‘aching’ legs)
  • skin changes associated with chronic venous insufficiency (e.g. venous eczema or haemosiderin deposition)
  • ssuperficial thrombophlebitis
  • venous leg ulcer (active or healed)
74
Q

what tx can vasc surgeons do for patient with venous disease

A
  • endothermal ablation
  • injection / foam sclerotherapy
  • surgery (ligation / stripping)

Y6 Senior Surgery (10 decks)

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